Can you explain the ways in which you identify near-miss incidents?
BM: I define “near-miss”
Near-miss incidents happen so quickly that when it’s all over everyone involved realizes that they came close to a disaster that did not happen.
How do you overcome these?
BM: The near miss is usually not overcome but survived and usually by sheer luck. These are events that happen and no one saw them coming. They expose the blind spots in our thinking about operations and maintenance because those involved were not conscious of the forces or blind to the dangers present.
Once they happen, an after-action review can identify the causes. This consciousness raising can then allow everyone to be aware of the blind spots and thus be forewarned to avoid the chain of events that could lead to disaster.
What advice would you give to other hydro plants to ensure they are operating safely?
1) Have a strong active safety program where deliberate review and training around the high hazard activities of the job occurs for all maintenance and operations personnel.
2) Conduct After-Action Reviews for both the mistakes and near-miss incidents that occur.
3) Be aware of the biases in cognitive thinking that can blind us to seeing the danger in a situation.
4) Don’t bury and ignore the near-miss incidents because “it will make us look bad.”
5) As an organization, learn by telling the stories of the mistakes and near-miss incidents to teach and train the personnel who are responsible for operating and maintaining the plant safely.
What are the common blind-spots and what strategies do you use to prepare for them?
BM: Hydro by its nature involves the control and manipulation of the largest forces in nature for the benefit of the community: water under pressure, flowing water, large machinery in motion, high-voltage electricity, heavy machinery and equipment, high pressure oil and gas systems, etc. Making changes in the application of these forces and energy requires understanding and respect for what we are doing. Therefore, if those who do the operations and maintenance are unskilled or have allowed themselves to become complacent about what they are doing and do not logically think through what they are doing, disaster has a higher chance of occurring. Being conscious of the routines and aware of the potential pitfalls is the first strategy. This can be done by having a discussion each morning among the staff about what is going to happen that day, and what to watch for when doing it.
Alternately, changes to operations and maintenance which involve the application of non-routine complex practices and procedures to be successful also require a conscious understanding of the necessary steps to avoid disaster. Taking a unit down for maintenance involves shutdown sequences and opening up spaces that normally are not open. The safe execution of the sequence of steps is critical to safe success. Again a review at the beginning of each day with the crew can clarify and illuminate the needs of all parties for success and pitfalls to avoid.
Programs for regular training of staff on the equipment, protective clothing, and safe practices are essential for any utility to maintain a good safety record. This should include an opportunity for the less experienced staff to mentor or apprentice with the more experienced staff to develop their intuitive capacities for sensing problems before they actualize.
I believe successful utilities have an open policy, which emphasizes review of near-miss incidents with the purpose to discover what the system collectively does not know and can learn from such events.
Bruce Meaker is a 28 year employee of PUD #1 of Snohomish County where he is responsible for the operating and dam safety requirements of the 112 MW Henry M. Jackson Hydroelectric Project. During his career, he has been the Project Manager, Dam Safety Engineer, EAP Coordinator, and Regulatory Affairs Manager responsible for project license compliance.
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